GDT in Septic Shock

VERA IRAWANY
• Septic shock  Sepsis-induced hypotension
persisting despite adequate fluid resuscitation

• Sepsis-induced tissue hypoperfusion  infection-induced

hypotension, elevated lactate or oliguria

SSC 2013

WHAT IS SEPTIC SHOCK?

WHAT’S GOAL DIRECTED THERAPY (GDT) ?
EGDT – RIVER’S PROTOCOL
Comparing mortality outcome of septic
shock between Standard Therapy with
EGDT

STANDARD CARE:
 CVP
 MAP
 UO

EGDT for ≤ 6 hours with continueScvO2

monitoring:
 CVP
 MAP
 UO
 ScvO2
 SaO2
 Hematorit
 Cardiac Index
 VO2
 Figure,S1.,–,Protocol,for,early,goal9directed,therapy,(EGDT).,

Protocol:
1. Insert CVC and AL and
continous monitoring of
ScvO2
2. 500 mL crystalloid every 30
min  CVC 8-12 mmHg
3. If MAP ≤ 65 mmHg 
vasopressor
4. If ScvO2 ≤ 70%  transfuse
PRC to achieve hematocrit at
least 30%
5. If ScvO2 still ≤ 70% 
dobutamin start 2.5
mcg/kg/min  titrated every
30 min, max 20 mcg/kg/min
6. Reduce VO2 by sedatives and
mech. ventilation

,
 ;;

RESULT : 46.5% VS 30.5%

How to manage septic shock?
What the guideline said? And how’s the
evidence...
Fluid
Drug 1 : Vasopressor
Drug 2: Inotropic
… THE EVIDENCES …
ProCESS STUDY
 • 31 emergency departement in US
• 1341 patient with septic shock
• Divided into 3 groups:
1. Protocol-based EGDT  River’s protocol
2. Protocol-based standard therapy  didn’t require
CVC, or administration of inotropic or blood transfusion
3. Usual care

Methods
 Figure,S1.,–,Protocol,for,early,goal9directed,therapy,(EGDT).,

Protocol:
1. Insert CVC and AL and
continous monitoring of
ScvO2
2. 500 mL crystalloid every 30
min  CVC 8-12 mmHg
3. If MAP ≤ 65 mmHg 
vasopressor
4. If ScvO2 ≤ 70%  transfuse
PRC to achieve hematocrit at
least 30%
5. If ScvO2 still ≤ 70% 
dobutamin start 2.5
mcg/kg/min  titrated every
30 min, max 20 mcg/kg/min
6. Reduce VO2 by sedatives and
mech. ventilation

EGDT ,
Protocol:

1. Peripheral iv access
2. 500-1000 ml fluid bolus
3. Targets SBP ≥ 100mmHg; SI ≥
0.8
4. If fluid overload  vasopressor
5. If still not achieved  bolus `
another isotonic IVF250-500 ml
per hour
6. Reassess q30 min
7. Monitor fluid overload, recheck
lactate and HCT

Standard Therapy
Outcome
 $
$
Panel$A$–$time$(minutes)$until$a$central$venous$catheter$is$placed.$Panel$B$–$time$(minutes)$until$a$central$venous$catheter$for$oximetric$
monitoring$is$placed.$Central$venous$catheterization$defined$as$use$of$oximetric$catheter$or$multiple$serial$ScvO
Panel$A$–$time$(minutes)$until$a$central$venous$catheter$is$placed.$Panel$B$–$time$(minutes)$until$a$central$venous$catheter$for$oximetric$ 2$measures.$Panel$C$–$$
monitoring$is$placed.$Central$venous$catheterization$defined$as$use$of$oximetric$catheter$or$multiple$serial$ScvO $measures.$Panel$C$–$$
2
Intravenous$fluid$volume$by$hour$(mean$+$SD).$Panel$Intravenous$fluid$volume$by$hour$(mean$+$SD).$Panel$D$–$use$of$resuscitation$interventions.$ScvO
D$–$use$of$resuscitation$interventions.$ScvO $–$central$venous$oxygen$saturation;$PRBC$–$ 2$–$central$venous$oxygen$saturation;$PRBC$–$
Panel$A$–$time$(minutes)$until$a$ central$venous$catheter$is$placed.$Panel$B$–$time$(minutes)$
packed$red$blood$cell;$EGDT$–$early$goalHdirected$therapy..$
2
until$a$central$venous$catheter$for$ox
PPvalues$represent$comparisons$across$the$3$arms.$
packed$red$blood$cell;$EGDT$–$early$goalHdirected$therapy..$
RESULT: NO DIFFERENCE
Conclusion
ARISE STUDY
• Emergency departement in 52 centres (mostly AUS or
NZ)
• 1600 patients with early septic shock
• Divided into 2 groups:
1. Protocol-based EGDT  River’s protocol
2. Usual care

Methods
Outcome
Probability of Survival
Odd ratio for death 90 days
Conclusion
ProMISE STUDY
… Thank you …
… Terima kasih …
… Syukron katsiran …